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RED ROCK DIAGNOSTICS, LLC - LIEN
Attorney Firm Information
Name:
Address:
Patient Information
Name:
S.S. #:
Birth Date:
Accident Date:
Phone No.:
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I do hereby authorize Red Rock Diagnostics, LLC to furnish the above attorney and/or insurance carrier with all records
regarding the accident/injury for which I am receiving or have received treatment at __________________ beginning on
_____/_______/______. (Date of Service)
I hereby authorize and direct you, my attorney and/or insurance carrier, to pay directly to Red Rock Diagnostics, LLC such sums
as may be due and owing for services rendered me both by reason of this accident and by reason of any other bills that are due
and to withhold such sums from any settlement, judgment, or verdict which may be paid to you, my attorney, to myself or to
another individual on my behalf, and/or by you the insurance carrier, as may be necessary to adequately protect and clear my
account at Red Rock Diagnostics, LLC for services rendered at ________________. I hereby give a Lien on my case to Red
Rock Diagnostics, LLC against any and all proceeds of any settlement, judgment, or verdict which may be paid to you, my
attorney, or myself or to another individual on my behalf, and/or by you the insurance carrier, as the result of the injuries for
which I have been treated or injuries in connection therewith.
I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the
event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and
enforceable upon the case as if it were executed by him/her.
I fully understand that I am directly and fully responsible to Red Rock Diagnostics, LLC for all bills submitted for service rendered
me by ________________ and that this agreement is made solely for additional protection and in consideration of awaiting
payment. And, I further understand that such payment is not contingent on any settlement, judgment or verdict by which I
may eventually recover said fee.
Interest on this lien is 18% per annum, commencing 30 days from the date of payment of settlement, judgment or award
relating to services provided by _______________ and purchased by Red Rock Diagnostics, LLC.
I waive the Statute of Limitation regarding Red Rock Diagnostics, LLC right to recover.
It is understood and agreed that a copy of this lien shall have the same force and effect as the original.
Date:
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Patient’s Signature:
The undersigned attorney of record and/or insurance carrier for the above patient does hereby agree to observe all the terms
of the above and agrees to withhold such sums from any settlement, judgment or verdict, as may be necessary to adequately
protect Red Rock Diagnostics, LLC and to disperse such sums as per lien.
Date:
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***** Please Sign, date, and return to:
Version August 2012
Attorney’s Signature:
Red Rock Diagnostics, LLC
P.O. Box 26119
Las Vegas, NV 89126
Fax: (702) 362-5132